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Emergency Department Diversions: Hospital and Community Strategies Alleviate the Crisis

Issue Brief No. 78March 2004
Linda R. Brewster, Laurie E. Felland

A nationwide surge in emergency department ambulance diversions in 2000-01
raised concerns about access and quality of care for critically ill patients, but the
diversion problem has improved markedly over the past two years, according to
findings from the Center for Studying Health System Changes (HSC) 2002-03 site
visits to 12 nationally representative communities. Hospital efforts to improve bed
management and patient flow, as well as community initiatives to monitor and
control diversions, have played key roles in easing the problem. The success in bringing
the diversion crisis under control offers an important lesson for policy makers—much can be done to better manage existing hospital capacity before potentially
costly expansions are made.

Emergency Department Diversion Crisis Cools Down

lthough emergency department
(ED) ambulance diversions still
occur, HSCs 2002-03 site visits to 12
nationally representative communities
found they are no longer as frequent
or as unmanageable (see Data Source).
Even communities with severe diversion
problems, such as Boston, Cleveland
and Phoenix, have stabilized over the
past two years (see box below).

A recent slowing of inpatient hospital utilization1
likely accounts for some of the drop in diversions. However, efforts on the
part of hospitals and community agencies have been critical in abating the diversion
problem. Many hospitals in the 12 communities have expanded or plan to expand
ED capacity to reduce crowding at the point of intake and help improve the efficiency
of their emergency services. But since emergency department bottlenecks stem
primarily from a lack of critical care beds and regular floor beds, hospitals
most important strategies have focused on these broader hospitalwide issues.
Similarly, community efforts have centered on improving coordination across
hospitals to help manage capacity problems across local health systems as a
whole.

Hospitals Adjust to Shifts in Supply and Demand

verflowing EDs in 2000-01 were a highly visible symptom
of an emerging mismatch between supply and demand for hospital services. Hospital
administrators efforts to address this problem over the past two years primarily
have centered on better capacity management through a focus on three main areas:
1) staffing, 2) bed availability and 3) patient flow within and out of hospitals.

Staffing. The severe nursing shortage that emerged in 1998 and still
persists has been a major contributor to diversions and hospital capacity problems.
Over the past two years, hospitals have redoubled efforts to fill nursing vacancies,
turning to international recruiting and relatively expensive agency and traveling
nurses. They also have improved recruitment and retention of nurses by offering
financial incentives and flexible work schedules. Some hospitals are collaborating
with local schools to encourage students to enter nursing. While many of the
strategies are costly, these efforts have begun to help fill vacancies and allow
many hospitals to reopen—and in some cases add—beds to ease ED backups.

Staffing remains tight in many communities, and some hospitals report diversions
still occur sometimes because they are unable to staff all of their licensed
beds, but, overall, hospitals have made significant progress in finding ways
to use their nursing staff more efficiently. For example, hospitals have redesigned
nursing positions to eliminate non-nursing tasks, adding support staff to handle
administrative duties and nurses aides to assist with patient care. Some hospitals
introduced information technology on floor units for patient record keeping,
which has helped improve nursing efficiency by reducing time spent deciphering
physician handwriting, but such initiatives were limited to a few hospitals.

Growing physician unwillingness to serve on
hospitals on-call ED panels has been another
major staffing problem that has contributed
to diversions. Some specialists have become
reluctant to serve in the ED because they
receive no payment for treating uninsured
patients but still are exposed to the risk of
malpractice suits. By 2002-03, hospitals in
six of the 12 communities had begun to pay
certain specialists for on-call coverage—and
in some cases, compensate physicians for
services provided to uninsured emergency
patients—to maintain adequate ED coverage
and reduce diversions.

Bed Availability. Hospitals also have tried to improve use of existing
inpatient capacity. Many hospitals have increased the number of observation
beds or initiated clinical protocols to help reduce admissions from the ED by
shifting certain cases to outpatient programs. Some hospital systems have attempted
to better manage beds across affiliated facilities. For example, a large Boston
hospital system shifted patients from crowded downtown hospitals to community
hospitals with available space.

Freeing up ICU capacity has been especially
critical in stemming diversions. In each of
the 12 communities, hospitals occasionally
have diverted ambulances because ICU beds
were full, even if other inpatient beds were
available.Most hospitals have not expanded
ICU capacity, however, mainly because it is
so difficult to find qualified ICU nurses.
Instead, hospitals have focused on setting up
new units for postoperative or transitional
care that can relieve pressure on the ICU,
although some hospital administrators caution
that creating special purpose units can restrict
bed-use flexibility.

Some hospitals have hired hospitalists—physicians specializing in the care of hospitalized
patients referred by community physicians.
One hospital, for example, set up a short
stay—24 to 72 hours—medical/surgical unit
staffed by hospitalists to free up beds elsewhere
and help prevent readmissions. Another
hospital found that using hospitalists in the
ED cut the average length of stay for patients
admitted through the ED by two days,
increasing bed availability.

Many observers suggest that hospitals could
dramatically improve bed availability if they
exercised greater control over scheduling of
elective procedures, but hospitals have shied
away from this strategy largely because they
are wary of reducing surgeons productivity
and potentially prompting them to direct
their patients elsewhere. Indeed, quite to the
contrary, hospitals have continued to pursue
elective surgical care, both to boost their own
revenues and to avoid encouraging physicians
to shift this profitable business to specialty
hospitals and physician-owned ambulatory
surgery centers. In fact, some of the most
sought-after patients—such as high-margin
cardiac cases—frequently limit the availability
of critical care beds for emergency admissions.

Patient flow. Accelerating bed turnover to make room for additional
emergency admissions has been another key focus for hospitals to ease the diversion
problem. Almost every hospital visited had created "bed czars," or bed utilization
committees, to help expedite patient flow through the hospital. Bed utilization
committees typically are comprised of nurses armed with information systems
and mobile communication devices that provide real-time census data. The job
of these bed managers, as one hospital administrator put it, is to "work the
beds all day long" and to make appropriate transitions of care for patients
within and out of the hospital. Other strategies to aid bed turnover include
improving housekeeping procedures to make cleaning newly vacated rooms a priority
and adding space for discharged patients to wait for transportation so they
can leave their rooms as soon as possible.

In some hospitals, senior physicians and
nurses have been appointed to lead efforts to
speed patient discharges, bringing greater
finesse to the often-delicate task of changing
physician practices. These individuals work
one-on-one with doctors to expedite discharges
and encourage medical staff to prepare
discharge orders earlier in the day.

Other hospitals have taken the approach
that providing information about potential
overflows will prompt physicians to adjust
their discharge decisions accordingly.
For example, when the inpatient census
approaches capacity, some hospitals place
red flags in doctors lounges to encourage
physicians to discharge patients as soon
as possible.

Efforts to improve patient flow also
have focused on the ICU. Many hospitals
have developed clinical protocols for ICU
procedures to help standardize care and
speed-up internal transfers to step-down
units. In addition, many hospitals have hired
intensivists—physicians board certified in the
subspecialty of critical care medicine—to
staff ICUs. Indeed, a Cleveland hospital
administrator reported that patient flow from
one of the hospitals ICUs markedly improved
when care decisions were made by intensivists
rather than by admitting physicians.

Although hospitals reported significant
improvements in patient flow over the
past two years, resistance from attending
physicians remained a barrier, complicated
by the fact that physicians have little incentive
to speed discharges in the current
fee-for-service payment environment. In
addition, sometimes a shortage of post-acute
care options—including skilled-nursing
facilities, long-term care beds and home
health services—limits hospitals ability to
hasten patient discharges.

Even in communities where there are
sufficient resources, post-acute care beds
are often filled preferentially with patients
who require short-term rehabilitation,which
is more profitable, leaving hospitals to search
for facilities that will accept long-term
patients or more complex patients.

Communities Improve Coordination and Oversight

ommunities have played an important
role in helping to bring the diversion crisis
under control by proactively managing
ambulance diversions across local hospitals.
Although there are no standard regulations
governing how hospitals or communities
monitor or control ambulance diversions,
model diversion protocols developed in late
2000 by the American College of Emergency
Physicians have provided guidance for
many communities.

Most of the 12 communities have established or updated guidelines to define
how long a diversion can last, the types of patients or conditions deemed "off
limits" from a diversion and the types of capacity limitations that warrant
a diversion. In Orange County, for instance, guidelines limit ED diversions
to two hours at a time unless the hospital notifies local emergency medical
services (EMS) about the situation, explaining why the ED cannot reopen, what
efforts are being taken to address internal problems and when the ED expects
to reopen.

In some communities, hospitals have
collaborated, sometimes with encouragement
from the local hospital association, to help
control diversions. In northern New Jersey
and Syracuse, for example, hospitals share
the load of ED patients and proactively
inform one another of capacity constraints
in an attempt to avoid a domino effect of
simultaneous diversions. Encouraging
hospitals to play by the same rules is an
important part of maintaining access to
emergency care throughout a community.

In other communities, the local EMS or
other planning body has become involved in
defining more rigorous procedures for diversions
and determining how many hospitals
may simultaneously divert ambulances. For
example, in Phoenix, a community task force
refined local diversion policies and procedures,
including implementing an Internet-based
communication tool through EMS that
connects every ED and provides real-time
monitoring to help ambulance drivers identify
which hospital has available beds. The state
hospital association was instrumental in purchasing
the online communication tool and
providing the public with diversion data.

Some communities, particularly those with
more severe diversion problems, have created
a more regional structure to monitor, control
and respond to diversions. In Boston, for
example, the regional EMS developed a complex
structure between EMS, the local health
department and area hospitals to coordinate
which hospitals may go on diversion at a given
time.Meanwhile, the states public health department,
which has oversight of the regional
EMS system, provides ongoing monitoring.
Clevelands Cuyahoga County instituted a
diversion policy to guarantee some coverage
in each of the countys four geographic
regions—every hospital is now assigned a
date and time when it will provide backup,
even if it means coming off diversion to do so.

Lessons Learned

he severity and sudden onset of the diversion
crisis compelled a quick response to avoid
serious threats to access and quality of care.
This pushed hospitals and communities to
look beyond simply adding more capacity to
alternative strategies to better manage existing
resources. Hospitals redoubled efforts to
adapt to the limited supply of nurses and
developed initiatives to improve patient flow
and free up beds. Both communities and
hospitals invested in improved monitoring,
coordination and oversight to better manage
capacity across local health care systems.

Notably, many of the strategies hospitals have adopted to help manage capacity
may pay dividends beyond helping to minimize the need for diversions. Hospitals
today are grappling with questions about long-term capacity needs, particularly
in the face of the aging baby boom generation, which has prompted predictions
of dramatic increases in hospital utilization.Many are responding with a rush
to build more beds. Yet, demand for hospital services can be tricky to predict,
as the recent slowdown in the inpatient utilization trend demonstrates. And,
the aging of the population is unlikely to have as significant an impact on
utilization trends as many expect.5 With such uncertain demand
forecasts, hospitals would be prudent to draw on the management expertise developed
to bring the diversion crisis under control as part of their response to longrun
capacity pressures. Indeed, hospitals and communities have shown there are a
variety of creative ways to make better use of existing capacity when pushed
to do so. State and federal policy makers would be wise to consider ways to
encourage such efforts before significant—and costly—capacity expansions
occur.

Diversions Then and Now in 12 Communities

Emergency department diversions—when ambulances are redirected from one
ED to another because a hospital cannot care for additional patients—had become
increasingly common during HSCs 2000-01 site visits, resulting from a growing
imbalance between supply and demand for hospital services.2 Part of the problem
stemmed from increased demand for emergency department services: ED visits
grew nationally by about 16 percent between 1996-97 and 2000-01.3

But hospital capacity constraints also played an important role.Managed care
pressures to lower utilization and reduce costs led many hospitals to downsize their
bed capacity and decrease staffing levels, eliminating much of the stand-ready capacity
for periods of peak demand.At the same time, hospitals sought to boost their revenue
by pursuing more profitable surgical cases, but the number of intensive care unit
(ICU) or cardiac-monitored beds available for new emergency patients declined.
Meanwhile, the emerging nursing shortage made it increasingly difficult to staff existing
beds. Finally, the move away from managed cares tight utilization controls led to
even more pressure on hospital bed capacity. Together, these pressures increasingly
led hospitals to board patients awaiting admission in their EDs, and, as EDs grew
ever more crowded, hospitals were forced to go on diversion more frequently.

Between 2000-02, both the frequency and duration of diversions increased dramatically
across the 12 communities, although there was wide variation in the severity
of the problem across these communities. At one end of the spectrum was Little
Rock, a community that historically had excess hospital capacity. During 2002, one
or more of the largest hospitals in Little Rock would go on diversion sporadically
because of a shortage of staff or critical care beds. In other markets, diversions were
limited to particular hospitals, as in Greenville where population growth and rising
utilization, along with exclusive health plan contracts, pushed demand for services
beyond capacity at the countys largest hospital. And, in Orange County, rapid population
growth in the southern part of the county has outpaced efforts to expand
hospital capacity and left this area with a severe diversion problem that persists
today. At the extreme were Cleveland, Phoenix, Boston and Miami, where diversions
would sometimes spread from one hospital to another in a domino effect and
threaten to put ambulances into gridlock.

All 12 communities have made significant progress in bringing diversions under
control over the past two years. Even in communities with the most severe diversion
crises, hospitals total hours on diversion have stabilized or begun to decline. In Phoenix,
for example, hospitals hours on diversion decreased for the first time in three years
in the first quarter of 2003, and in Boston, hospitals hours on diversion during 2003
were 7 percent less than in 2002.4 Yet, observers in Boston and Phoenix still consider
diversions to be a serious problem since one or more hospital EDs in these metropolitan
areas is closed to ambulances all the time.With hospital capacity stretched in many
markets, ED diversions will likely remain a chronic—but more manageable—problem.

Data Source

Every two years, HSC researchers visit 12 nationally representative metropolitan
communities to track changes in local health care markets. The 12 communities
are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing,Mich.; Little
Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle;
and Syracuse, N.Y. HSC researchers interviewed key individuals in each community,
including representatives of hospitals, physician groups, local health departments
and government officials and other stakeholders. This Issue Brief is based on
analysis of these individuals assessments of hospital efforts to reduce emergency
department diversions as well as community initiatives to monitor and control
diversions.